TO PROVIDE THE VERY BEST CARE FOR EACH PATIENT ON EVERY OCCASION Medical treatment for ectopic pregnancy/ pregnancy of unknown location with Methotrexate An information guide
Medical treatment for ectopic pregnancy/ pregnancy of unknown location with Methotrexate Sadly, you have been told that your pregnancy is either an ectopic pregnancy which is a pregnancy that has developed outside of the womb (uterus), or a pregnancy of unknown location, (PUL), where the pregnancy hormone is raised but we have not identified a pregnancy on an ultrasound scan. You have discussed options for treatment with your doctor and together you have decided on the option of medical management. The information in this leaflet gives advice on medical treatment for ectopic pregnancy, or PUL with a medication called methotrexate. If you have any questions, please do not hesitate to ask the doctors or nursing staff for advice. What is an ectopic pregnancy? When you become pregnant the egg and sperm meet in the fallopian tube, (this is the tube which carries the egg from the ovary to the womb). Typically, the fertilized egg then moves to the womb and the pregnancy will mature. If the fertilized egg does not move and stays in the fallopian tube, an ectopic pregnancy could begin to develop. Ectopic pregnancies can also occur in other areas, such as the abdomen or ovary, but this is rare. Ectopic pregnancy affects around one in ninety pregnancies. 2
What is a pregnancy of unknown location? In this condition, there is a positive pregnancy test with no sign of pregnancy either inside or outside of the womb. What is methotrexate? Methotrexate is a cytoxic drug, which has been used to treat various conditions for many years. It is used to treat an ectopic pregnancy, as it works, in most cases, by temporarily interfering with the processing in the body of the vitamin folate. This is essential for rapidly growing cells like those in an ectopic pregnancy. Methotrexate stops the pregnancy from developing any further, and the body then gradually reabsorbs the cells. What are the risks of medical treatment? There is a 7% risk that the ectopic pregnancy could rupture. If this happens you may feel faint or dizzy, have abdominal pain, shoulder tip pain and/or have a heavy vaginal bleed. If you do experience any of these symptoms you should seek medical advice immediately. In this situation you will require emergency surgery to remove the ruptured tube. There is a risk that the injection of methotrexate will not work. If this happens you may require a second treatment. Fifteen out of a hundred women (15%), will need to have a second injection of methotrexate. Even after a second injection of methotrexate, 7 in 100 women (7%) will need surgery. What are the side effects of methotrexate? Side effects include mild abdominal pain, nausea, diarrhoea, hair loss and skin rashes. Methotrexate can also affect the blood count (one of the effects is that fewer blood cells are made) making you prone to infections. 3
Methotrexate is not appropriate if you suffer from any of the following conditions: infection impaired kidney function severe anaemia liver disease HIV/AIDS Before treatment is commenced Your doctor will check that you are medically suitable for the treatment, and that you are able to attend follow up appointments in order to monitor the pregnancy hormone in your blood. Blood tests are required to be taken on day 4 and day 7 following the administration of methotrexate (day 1) and it is important that you are able to attend. How is methotrexate given? It is given into the large muscles of your buttocks. Depending on the dose it may be given as two injections. Each dose of methotrexate is calculated and prepared by the pharmacy department. In order to do this we will have to measure your height and weight. Blood will be taken from you to check that your blood count, liver and kidney functions are normal. You do not need any form of anaesthetic for this procedure. Do I need to stay overnight? After the injection, nursing staff will observe you for 30 60 minutes for any reactions to the medication. If you are well, and showing no side effects, you may be dischargd home, once you have been given your follow up appointments. If you do feel 4
unwell or are showing any effects from the medication, you will be admitted to the gynaecology ward for observation. What will happen after treatment? We advise that you are not left alone after treatment and that you have somebody with you when you are discharged. We ask you to monitor your level of pain and bleeding and if it becomes excessive to seek medical advice. After your medication you will require follow up appointments so that we can observe the effects of the treatment and monitor the pregnancy hormone levels in your blood. You will be given follow up for repeat beta human chorionic gonadotropin (BHCG) blood tests on day 4 and day 7 after your treatment. After the results of the second blood test we will consider if further treatment is needed and advise you on your future plan of care. If you have methotrexate, we will need to monitor your BHCG until it is below 25. It can take up to 6 weeks for your blood levels to be within a normal range. It is important that you attend all follow-up appointments. What to avoid after treatment avoid alcohol and folic acid until your blood levels have returned to normal avoid direct sunlight during treatment avoid Aspirin and medication such as Ibuprofen for 1 week after treatment,(if you need to take these medications, please discuss this with your doctor) do not have sexual intercourse until you have finished bleeding avoid getting pregnant for three to six months. 5
When to seek medical advice You should seek immedidate medical advice if you develop any of the following: severe abdominal pain heavy bleeding feeling dizzy or generally unwell sore throat fever symptoms of infection unexplained bruising or bleeding, jaundice (eyes or skin turning yellow). If symptoms are severe you need to attend your nearest accident and emergency department. In an emergency call 999 for an ambulance. What about the future? It is advised that you do not become pregnant for 3-6 months after your BHCG is negative. To avoid becoming pregnant you should use a form of contraception. This can be discussed with your doctor. Most women who experience an ectopic pregnancy do not have a repeat experience, however there is a small chance that this could occur again. If or when you do become pregnant again you should be referred early in pregnancy to the gynaecology assessment unit (GAU) for an assessment, to ensure that the pregnancy is in the womb. In most cases a scan at 5-6 weeks gestation will be able to identify a very early intrauterine pregnancy. 6
When is it safe to have sex again? It is recommended that you wait until you have finished bleeding. It is advised that you use a form of contraception to avoid pregnancy and you should discuss this with your doctor or family planning clinic. Resuming a sexual relationship may be quite stressful for both of you. It is important to give each other time and to talk openly about your feelings. When is it safe to resume normal activities? You may feel tired and emotional and you may need to discuss going back to work with your doctor. In general, as long as you are felling well and your hormone levels are dropping you can resume normal activities. Strenuous activities should be avoided for around a month. How long before your next period? Some vaginal bleeding may occur after treatment with methotrexate. For some women this lasts for only a few days, for others there may be spotting for up to 6 weeks. When bleeding has stopped, the average time for the first period to arrive is 4 weeks, but it could be anytime between 2 and 10 weeks. The first period may be lighter or heavier than usual and may be more or less painful. There are no hard and fast rules. Periods may also be a little irregular in the early cycles after treatment and can occur between 23 and 42 days. If this irregularity persists after 3 cycles, you should speak to your doctor. Can anything be done to prevent another ectopic pregnancy? As ectopic pregnancy is more related to past tubal damage than the present, there is little to be done to prevent it from happening again. However, if you feel there may be ongoing problems of pelvic infection, such as chlamydia then testing and antibiotic treatment for this could help to reduce the risk of future ectopic pregnancy. 7
Counselling We understand that this is an emotional time for you and your family. If you feel that you need to talk to someone about your emotions and feelings you can contact Pam Brooks, counsellor on 0161-720-2969. Contact numbers We are here 24 hours a dy for support and advice. You can speak to a member of staff at: Gynae Assessment Unit (GAU) Oldham on 0161 627 8855 Gynae Assessment Unit (GAU) North Manchester on 0161 720 2211 Ward F1, Oldham on 0161 627 8857/8859 For further advice please contact: The Ectopic Pregnancy Trust at www.ectopic.org.uk Miscarriage Association at www.miscarriageassociation.org.uk 8
References: National Institute for Health and Clinical Excellence NICE Clinical Guideline 154. December 2012 Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer - Confidential Enquiry into Maternal and Child Health (CEMACH 2006-2008) Guidelines for the Management of Early Gestational Sac (EGS) Pregnancy of Unknown Location (PUL) and Suspected / Confirmed Ectopic Pregnancy, CPWC007 Medical Treatment with Methotrexate, The Ectopic Pregnancy Trust, (2013) Royal College of Gynaecologists, Ectopic Information For You, (2010). 9
10
11
If English is not your frst language and you need help, please contact the Ethnic Health Team on 0161 627 8770 Jeżeli angielski nie jest twoim pierwszym językiem i potrzebujesz pomocy proszę skontaktować się z załogą Ethnic Health pod numerem telefonu 0161 627 8770 For general enquiries please contact the Patient Advice and Liaison Service (PALS) on 0161 604 5897 For enquiries regarding clinic appointments, clinical care and treatment please contact 0161 624 0420 and the Switchboard Operator will put you through to the correct department / service Date of publication: February 2015 Date of next review: February 2018 Ref: PI (WC)_851 The Pennine Acute Hospitals NHS Trust Wood pulp sourced from sustainable forests www.pat.nhs.uk